Railroad Medicare Releases Results of Ambulance Claim Review

The Study

A little over a week ago, Palmetto GBA, the Medicare Administrative Contractor (MAC) for the Railroad Medicare program, issued the findings derived from a review of incoming ambulance claims they completed between October and December 2012.

Palmetto GBA’s Medical Review (MR) department completed what they termed as a “widespread review” of specific ambulance services for dates of service in the last quarter of 2012.

The Focus: BLS Non-Emergency

Just like many other MAC’s across the United States, Palmetto/Railroad Medicare viewed a total of 2,076 services that were billed as BLS Non-Emergency claims.

We suspect that this falls in line with recent government-sponsored studies, such as the recent MedPAC report to Congress, that showed an increase in the number of services billed to Medicare as BLS Non-Emergency trips along with a growing citation that the medical necessity for these trips is suspect.

The Numbers

The findings were somewhat concerning. The study concluded that of the 2,076 service claims reviewed, a total of 908 were denied for payment while 1,168 were approved. This equates to a claim error rate of 43.9%.

The largest percentage of denials came for trips that included the Origin/Destination Modifier RG or Residence to Hospital-Based Dialysis Facility. While the number of claims was small for this combination, 17, the error rate equated to 50.9% for rejection as 9 or the 17 claims were denied for payment.

The largest number of claims denied came for modifier HN or Hospital to Skilled Nursing Facility. In this category, 1,262 claims were reviewed with 544 of those claims denied for payment by Palmetto GBA at an error rate of 43.5%. This is particularly interesting as the bulk of the claims reviewed were for that very common transport segment within the ambulance industry.

Top Denial Reason— Insufficient Documentation!

When issuing their findings, Palmetto GBA provided the top denial reasons and broke them down with reasons they issued the denials.

The largest number of claims denied, across all Origin/Destination combinations, totaled 487 services, all denied because of insufficient documentation! Palmetto GBA explained that this was due to a combination of no Physician Certification Statement (PCS) and/or documentation submitted to support medical necessity for the trips.

Also they noted, within this particular denial category, that they found PCS’s that weren’t dated within the appropriate time frame and PCS’s not signed by the appropriate health care professional. In some cases no run sheet was submitted or the run sheet was for another patient and/or with an incorrect date of service.

I found it particularly interesting that they mentioned they denied some of these claims because the Patient Care Reports were missing crew member information and/or credentials.

Another Method of Transportation

A total of 232 claims in the survey, or about 11% of the claims reviewed, were denied because they were deemed by Palmetto GBA to not be “reasonable and necessary.”

This means that, “The documentation provided (to support the claim- PCR, PCS, etc.) did not support the patient’s condition was such that use of any other method of transportation was contraindicated.”

Other Reasons

Signatures were reviewed and became an issue. We’re not surprised. We’ve been warning our clients that patient, provider and health care professional signatures would be audited and figure into the Medicare equation as time moves forward.

Palmetto GBA denied 115 services where the PCS had an illegible signature or was missing the appropriate person’s signature or where the PCR was missing crew member signatures or those signatures were illegible (Yikes! Illegible crew signatures become a cause for denial?)

But the majority of signature issues were denied (97 of the 115) because the beneficiary (patient) signature requirements were not met and they broke those out for specifically having denied for the lack of signature, persons signing on behalf of patients who were not properly identified and/or the beneficiary signature was not dated.

Think about it…nearly 100 claims denied for something as “simple” as a signature.

Finally, 32 trips were denied because Palmetto GBA was billed for transportation to a doctor’s office for an appointment (non-covered destination for Medicare) and also for billing to the program for beneficiaries enrolled in hospice care which Medicare Part B is not the payer source.

More to Come

Palmetto GBA closed out its release of this review by stating that…”Because of the consistent high error rate,…” their MR Department will continue to conduct prepayment reviews for the BLS Non-Emergency level of service.

We don’t find this surprising at all. We’ve all been warned this is coming and now it’s here.

What’s It All Mean?

Given these kinds of negative results from reviews, it’s going to mean that the ambulance industry will be continually scrutinized and experience a growing audit/review climate. For some ambulance companies it will mean slowed or interrupted payments while claims are reviewed, prepayment. This alone can be very painful, not to mention the time and resources it takes to respond to questions posed by the MAC.

The BLS Non-Emergency part of the pre-hospital transport industry is now officially under the microscope. You’ll recall that MedPAC recommended that payments to this segment of the industry be cut drastically and the number of notations coming from CMS on their findings of widespread fraud and abuse within that segment of the industry is alarming.

What can I do?

Now is the time to review every segment of your non-emergency business, especially the BLS side of the equation. Frankly, that’s something that every ambulance service should be doing.  Monitoring compliance is one of the most important tasks that you can undertake. We suggest the following…

  1. Communicate with your street crews that this has become serious business. Make documentation training and education a mandate and a priority.
  2. Communicate with your billing office (in-house or outsourced) about these findings.
  3. Ask questions. Perform internal reviews before the claims go out to the MAC. Are you billing for services that just aren’t supported?
  4. Network. Share information with other ambulance administrators. Find out what others are doing. Engage consultants and/or reputable outsourcing contractors (like Enhanced) to ensure that your Compliance is not happening by accident or to ensure that it’s happening at all.  Enhanced was one of the first all-EMS billing companies in the Nation to have put in place a fully working, written compliance plan. We’re fanatical about compliance!

Time for a New Direction?

Maybe it’s time to consider a different direction. You may be sitting at your desk right now looking at claim rejection after claim rejection. Do you have the time and resources to adequately review each claim by yourself? Is your billing staff just not cutting it? Are your supervisors and street-level staff receiving the right amount of feedback regarding the integrity of the information they are forwarding following the run (PCR’s, PCS’s, signatures,)?

These are all items that a qualified and reputable billing contractor can assist your department by providing solutions to these and many other issues.

If you’re not outsourcing, maybe it’s time to see what benefits can result from making such a move.

If you are outsourcing, maybe your contractor doesn’t appreciate the need to continually communicate with you regarding what they are seeing that may cause issues in support of the claims they are billing on your behalf. In fact, if your contractor doesn’t have Certified Ambulance Coder (CAC) trained staff members, the people working your claims may not even understand the need for careful review and critical communication back to the client.

We take our responsibility very seriously. Our CAC certified staff is continually updated on all the latest rules and regulations and they frankly know exactly what to look for when it comes to documentation requirements and overall compliance needs.

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